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Attributes | |
ACN | 695916 |
Time | |
Date | 200605 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | general aviation : instructional |
Make Model Name | PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Flight Phase | cruise : level |
Person 1 | |
Affiliation | other |
Function | maintenance : inspector |
Qualification | technician : inspection authority |
Experience | maintenance technician : 8 |
ASRS Report | 965916 |
Person 2 | |
Affiliation | other |
Qualification | technician : airframe technician : powerplant technician : inspection authority |
Experience | maintenance lead technician : 30 |
ASRS Report | 696102 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : 3 |
Resolutory Action | flight crew : landed in emergency condition |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : testing performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On may/thu/06 we had a PA28R-201 aircraft that was scheduled for a phase inspection. One of the discrepancies involved removing and reinstalling the #4 aft engine baffle. In doing so; the fuel lines to the fuel flow divider had been removed to facilitate maintenance. After reinstalling the aft #4 engine baffle; the technician put the fuel line on hand tight. The fuel line was never torqued to the proper valve. After inspecting the baffle installation; I overlooked that the fuel line was removed to facilitate maintenance. At the completion of the phase; the aircraft was ran up and leak checked. There were no leaks noticed at this time. On may/fri/06; the aircraft was dispatched and flew until the aircraft's engine quit running. An emergency landing was performed with no injury or damage to the aircraft or persons on board. The fuel line on the fuel flow divider had only 2 threads left on the nut before becoming completely disconnected. Cause of engine failure was due to a loose fuel line at the fuel flow divider. This led to fuel starvation.
Original NASA ASRS Text
Title: A PA28R-201 MADE AN EMER LNDG DUE TO ENG LOSS OF PWR FUEL LINE AT FLOW DIVIDER WITH LOOSE 'B' NUT CONNECTION.
Narrative: ON MAY/THU/06 WE HAD A PA28R-201 ACFT THAT WAS SCHEDULED FOR A PHASE INSPECTION. ONE OF THE DISCREPANCIES INVOLVED REMOVING AND REINSTALLING THE #4 AFT ENG BAFFLE. IN DOING SO; THE FUEL LINES TO THE FUEL FLOW DIVIDER HAD BEEN REMOVED TO FACILITATE MAINT. AFTER REINSTALLING THE AFT #4 ENG BAFFLE; THE TECHNICIAN PUT THE FUEL LINE ON HAND TIGHT. THE FUEL LINE WAS NEVER TORQUED TO THE PROPER VALVE. AFTER INSPECTING THE BAFFLE INSTALLATION; I OVERLOOKED THAT THE FUEL LINE WAS REMOVED TO FACILITATE MAINT. AT THE COMPLETION OF THE PHASE; THE ACFT WAS RAN UP AND LEAK CHKED. THERE WERE NO LEAKS NOTICED AT THIS TIME. ON MAY/FRI/06; THE ACFT WAS DISPATCHED AND FLEW UNTIL THE ACFT'S ENG QUIT RUNNING. AN EMER LNDG WAS PERFORMED WITH NO INJURY OR DAMAGE TO THE ACFT OR PERSONS ON BOARD. THE FUEL LINE ON THE FUEL FLOW DIVIDER HAD ONLY 2 THREADS LEFT ON THE NUT BEFORE BECOMING COMPLETELY DISCONNECTED. CAUSE OF ENG FAILURE WAS DUE TO A LOOSE FUEL LINE AT THE FUEL FLOW DIVIDER. THIS LED TO FUEL STARVATION.
Data retrieved from NASA's ASRS site as of January 2009 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.